Implementing paediatric early warning scores systems in the Netherlands: future implications.

BACKGROUND: Paediatric Early Warning Scores (PEWS) are increasingly being used for early identification and management of clinical deterioration in paediatric patients. A PEWS system includes scores, cut-off points and appropriate early intervention. In 2011, The Dutch Ministry of Health advised hospitals to implement a PEWS system in order to improve patient safety in paediatric wards. The objective of this study was to examine the results of implementation of PEWS systems and to gain insight into the attitudes of professionals towards using a PEWS system in Dutch non-university hospitals. METHODS: Quantitative data were gathered at start, midway and at the end of the implementation period through retrospective patient record review (n = 554). Semi-structured interviews with professionals (n = 8) were used to gain insight in the implementation process and experiences. The interviews were transcribed and analysed using an inductive approach. RESULTS: Looking at PEWS systems of the five participating hospitals, different parameters and policies were found. While all hospitals included heart rate and respiratory rate, other variables differed among hospitals. At baseline, none of the hospitals used a PEWS system. After 1 year, PEWS were recorded in 69.2% of the patient records and elevated PEWS resulted in appropriate action in 49.1%. Three themes emerged from the interviews: 1) while the importance of using a PEWS system was acknowledged, professionals voiced some doubts about the effectiveness and validity of their PEWS system 2) registering PEWS required little extra effort and was facilitated by PEWS being integrated into the electronic patient record 3) Without a national PEWS system or guidelines, hospitals found it difficult to identify a suitable PEWS system for their setting. Existing systems were not always considered applicable in a non-university setting. CONCLUSIONS: After 1 year, hospitals showed improvements in the use of their PEWS system, although some were decidedly more successful than others. Doubts among staff about validity, effectiveness and communication with other hospitals during transfer to higher level care hospital might hinder sustainable implementation. For these purposes the development of a national PEWS system is recommended, consisting of a "core set" of PEWS, cut-off points and associated early intervention.

Superior mesenteric artery aneurysm in a 9-year-old boy with classical Ehlers-Danlos syndrome.

A 9-year-old boy with the classical type of Ehlers-Danlos syndrome (EDS) developed a symptomatic aneurysm of the superior mesenteric artery. His EDS diagnosis had been confirmed biochemically and genetically. Vascular complications are known to be associated with the vascular type of EDS, but this is the first report of a child with classical EDS who developed a major vascular complication. Clinicians should be aware that severe vascular complications albeit rare, can also occur in classical EDS.

[18 years experience with mechanical ventilation in patients with Duchenne muscular dystrophy]. / 18 jaar ervaring met chronische beademing bij patiënten met spierdystrofie van Duchenne.

OBJECTIVE: To find out which patients with Duchenne muscular dystrophy are eligible for starting home mechanical ventilation and what the survival rate is. DESIGN: Retrospective. METHOD: In 48 patients with Duchenne muscular dystrophy who were treated with home ventilation from 1987, the results were assessed in the follow-up visit in February 2005. Initially, ventilation was only given through a tracheotomy (TPPV), but after starting up a multidisciplinary neuromuscular consultation, non-invasive ventilation (NIPPV) was offered in an earlier stage of the disease. The following data were derived from the outpatient medical record: indication for ventilation, vital capacity (VC), arterial blood gas values, duration of ventilation up to February 2005, survival and causes of death. RESULTS: 15 patients died. The 5-year survival rate was 75% from the start of mechanical ventilation and 67% (18/27) of the patients were still living at home at the time of the follow-up visit. The most important causes of death were cardiomyopathy (5/15) and tracheal bleeding (3/15). The group of patients who started ventilation before 1995 (n = 17) had a significantly smaller VC than the group (n = 31) who started after the neuromuscular consultation was set up. The PaCO2 during daytime was significantly higher in the group that started ventilation before 1995 compared to the group that started later. CONCLUSION: Home mechanical ventilation can be implemented effectively in patients with Duchenne dystrophy, with a 5-year survival of 75%.

Walking with continuous positive airway pressure.

A ventilator-dependent child had been in the paediatric intensive care unit (PICU) ever since birth. As a result, she had fallen behind considerably in her development. After 18 months, continuous positive airway pressure was successfully administered via a tracheostomy tube with a novel lightweight device. This enabled her to walk in the PICU. With this device, the child was discharged home where she could walk with an action range of 10 m. Subsequently, her psychomotor development improved remarkably. To the authors' knowledge, this is the first case report of a patient, adult or paediatric, who could actually walk with a sufficient radius of action while receiving long-term respiratory support.

Growth changes in the soft tissue facial profile.

Longitudinal growth changes in the soft tissue profile of 40 caucasians between the ages of 7 and 18 were studied. The sample consisted of 17 males and 23 females who had Class I dentitions and balanced faces at age 7 and 18 years. None of the subjects received any orthodontic treatment. Cephalometric radiographs were available, as a rule, on a yearly basis. Soft tissue thickness, measured at the nose, upper lip, lower lip and chin, as well as the length of the upper and lower lip, all increased by varying amounts over the period of the study. Females acquired more growth as a percentage of their adult size (at age 18) than males in all variables except the angle of inclination of the skeletal chin which increased more in males. The largest increase in relative size was noted in the nose measurements. In males, the nose had not attained adult size even at age 18. Upper lip length growth, on the other hand, in both males and females was complete by the 15th year. The difference between male and female lip length growth was clinically significant; the average aggregate increase in upper and lower lips combined in males was 6.9 millimeters compared to 2.65 millimeters in females. The total gain in thickness at laberale superius was over four times as much in males as in females and continued to increase in males even at age 18. The change in thickness of the soft tissue at pogonion was not large, an average of 2.4 millimeters in males and 1.5 millimeters in females. The major contribution to the anterior growth of the chin was translatory, contributed largely by growth in the skeletal length from pogonion to pterygomaxillary plane.

Growth changes in the nasal profile from 7 to 18 years of age.

Lateral head cephalograms of 17 male and 23 female subjects, aged 7 to 18 years, were evaluated for age changes in morphology and position of the nose with reference to the pterygomaxillary vertical plane. The study was confined to persons with normal facial profiles, normal overjets, and Class I molar relationships. Four linear and two angular dimensions were measured. Statistical analysis included the calculation of medians, Q ranges, proportion of growth completed at each age expressed as a percentage of the size of the variable at 18 years, and a pairwise correlation matrix. The results indicated that (1) increments in nose height, depth, and inclination are essentially complete in girls by 16 years of age, while continuing to increase in males up to and beyond 18 years; (2) the ratio of upper to lower nose heights remains at approximately 3:1 from 7 to 18 years in both sexes; (3) the ratio of nose depth to sagittal depth of the underlying skeleton changed from 1:2 at 7 years in both sexes to 1:1.5 in male subjects and 1:1.6 in female subjects at 18 years; (4) although upper nose inclination was similar for the two sexes, lower nose inclination was slightly larger in female subjects, especially after the age of 10 years; (5) persons with greater increments in nose depth than in nose height, or in nose depth than in the sagittal depth of the underlying skeleton, develop larger upper nose inclinations. The impact of nasal growth changes on orthodontic diagnosis and treatment planning was emphasized.